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RULE §510.41Facility Functions and Services

(a) Anesthesia services. If the hospital furnishes anesthesia services, these services shall be provided in a well-organized manner under the direction of a qualified physician. The anesthesia service is responsible for all anesthesia administered in the hospital.

  (1) Organization and staffing. The organization of anesthesia services shall be appropriate to the scope of the services offered. Anesthesia shall be administered only by:

    (A) a qualified anesthesiologist;

    (B) a physician (other than an anesthesiologist);

    (C) a dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under state law; or

    (D) a certified registered nurse anesthetist who is under the supervision, as set forth in the Medical Practice Act, Texas Occupations Code, Title 3, Subtitle B, and the Nursing Practice Act, Texas Occupations Code, Chapter 301, of the operating physician or of an anesthesiologist who is immediately available if needed.

  (2) Delivery of services. Anesthesia services shall be consistent with needs and resources. Policies on anesthesia procedures shall include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies shall ensure that the following are provided for each patient.

    (A) A pre-anesthesia evaluation by an individual qualified to administer anesthesia under paragraph (1) of this subsection shall be performed within 48 hours prior to the procedure.

    (B) An intraoperative anesthesia record shall be provided. The record shall include any complications or problems occurring during the anesthesia including time, description of symptoms, review of affected systems, and treatments rendered. The record shall correlate with the controlled substance administration record.

    (C) A post-anesthesia follow-up report shall be written by the person administering the anesthesia before transferring the patient from the recovery room and shall include evaluation for recovery from anesthesia, level of activity, respiration, blood pressure, level of consciousness, and patient color.

      (i) With respect to inpatients, a post-anesthesia evaluation for proper anesthesia recovery shall be performed after transfer from recovery and within 48 hours after the procedure by the person administering the anesthesia, registered nurse (RN), or physician in accordance with policies and procedures approved by the medical staff.

      (ii) With respect to outpatients, immediately prior to discharge, a post-anesthesia evaluation for proper anesthesia recovery shall be performed by the person administering the anesthesia, RN, or physician in accordance with policies and procedures approved by the medical staff.

(b) Dietary services. The facility shall have organized dietary services that are directed and staffed by adequate qualified personnel. However, a facility that has a contract with an outside food management company or an arrangement with another facility may meet this requirement if the company or other facility has a dietitian who serves the facility on a full-time, part-time, or consultant basis, and if the company or other facility maintains at least the minimum requirements specified in this section, and provides for the frequent and systematic liaison with the facility medical staff for recommendations of dietetic policies affecting patient treatment. The facility shall ensure that there are sufficient personnel to respond to the dietary needs of the patient population being served.

  (1) Organization.

    (A) A facility shall have an employee who is qualified by experience or training to serve as director of the food and dietetic service, and be responsible for the daily management of the dietary services. This employee shall be full-time in a hospital; the crisis stabilization unit employee does not have to be full-time.

    (B) There shall be a qualified dietitian who works full-time, part-time, or on a consultant basis. If by consultation, such services shall occur at least once per month for not less than eight hours. The dietitian shall:

      (i) be currently licensed under the laws of this state to use the titles of licensed dietitian or provisional licensed dietitian, or be a registered dietitian;

      (ii) maintain standards for professional practice;

      (iii) supervise the nutritional aspects of patient care;

      (iv) make an assessment of the nutritional status and adequacy of nutritional regimen, as appropriate;

      (v) provide diet counseling and teaching, as appropriate;

      (vi) document nutritional status and pertinent information in patient medical records, as appropriate;

      (vii) approve menus; and

      (viii) approve menu substitutions.

    (C) There shall be administrative and technical personnel competent in their respective duties. The administrative and technical personnel shall:

      (i) participate in established departmental or facility training pertinent to assigned duties;

      (ii) conform to food handling techniques in accordance with paragraph (2)(E)(vii) of this subsection;

      (iii) adhere to clearly defined work schedules and assignment sheets; and

      (iv) comply with position descriptions which are job specific.

  (2) Director. The director shall:

    (A) comply with a position description which is job specific;

    (B) clearly delineate responsibility and authority;

    (C) participate in conferences with administration and department heads;

    (D) establish, implement, and enforce policies and procedures for the overall operational components of the department to include, but not be limited to:

      (i) quality assurance;

      (ii) frequency of meals served;

      (iii) non-routine occurrences; and

      (iv) identification of patient trays;

    (E) maintain authority and responsibility for the following, but not be limited to:

      (i) orientation and training;

      (ii) performance evaluations;

      (iii) work assignments;

      (iv) supervision of work and food handling techniques;

      (v) procurement of food, paper, chemical, and other supplies, to include implementation of first-in first-out rotation system for all food items;

      (vi) menu planning; and

      (vii) ensuring compliance with Chapter 228 of this title (relating to Retail Food).

  (3) Diets. Menus shall meet the needs of the patients.

    (A) Therapeutic diets shall be prescribed by the physician(s) responsible for the care of the patients. The dietary department of the facility shall:

      (i) establish procedures for the processing of therapeutic diets to include, but not be limited to:

        (I) accurate patient identification;

        (II) transcription from nursing to dietary services;

        (III) diet planning by a dietitian;

        (IV) regular review and updating of diet when necessary; and

        (V) written and verbal instruction to patient and family. It shall be in the patient's primary language, if practicable, prior to discharge. What is or would have been practicable shall be determined by the facts and circumstances of each case;

      (ii) ensure that therapeutic diets are planned in writing by a qualified dietitian;

      (iii) ensure that menu substitutions are approved by a qualified dietitian;

      (iv) document pertinent information about the patient's response to a therapeutic diet in the medical record; and

      (v) evaluate therapeutic diets for nutritional adequacy.

    (B) Nutritional needs shall be met in accordance with recognized dietary practices and in accordance with orders of the physician(s) responsible for the care of the patients. The following requirements shall be met.

      (i) Menus shall provide a sufficient variety of foods served in adequate amounts at each meal according to the guidance provided in the Recommended Dietary Allowances, as published by the Food and Nutrition Board, National Academy of Sciences, National Research Council, Tenth edition, 1989, which may be obtained by writing the National Academy Press, 2101 Constitution Avenue, Box 285, Washington, D.C. 20055, telephone (888) 624-8373.

      (ii) A maximum of 15 hours shall not be exceeded between the last meal of the day (i.e. supper) and the breakfast meal, unless a substantial snack is provided. The facility shall adopt, implement, and enforce a policy on the definition of "substantial" to meet each patient's varied nutritional needs.

    (C) A current therapeutic diet manual approved by the dietitian and medical staff shall be readily available to all medical, nursing, and food service personnel. The therapeutic manual shall:

      (i) be revised as needed, not to exceed 5 years;

      (ii) be appropriate for the diets routinely ordered in the facility;

      (iii) have standards in compliance with the RDA;

      (iv) contain specific diets which are not in compliance with RDA; and

      (v) be used as a guide for ordering and serving diets.

(c) Governing body.

  (1) Legal responsibility. There shall be a governing body responsible for the organization, management, control, and operation of the facility, including appointment of the medical staff. For facilities owned and operated by an individual or by partners, the individual or partners shall be considered the governing body.

  (2) Organization. The governing body shall be formally organized in accordance with a written constitution or bylaws which clearly set forth the organizational structure and responsibilities.

  (3) Meeting records. Records of governing body meetings shall be maintained.

  (4) Responsibilities relating to the medical staff. The governing body shall:

    (A) ensure that the medical staff has current bylaws, rules, and regulations which are implemented and enforced;

    (B) approve medical staff bylaws and other medical staff rules and regulations;

    (C) determine, in accordance with state law and with the advice of the medical staff, which categories of practitioners are eligible candidates for appointment to the medical staff;

    (D) ensure that criteria for selection include individual character, competence, training, experience, and judgment;

    (E) ensure that under no circumstances is the accordance of staff membership or professional privileges in the facility dependent solely upon certification, fellowship or membership in a specialty body or society;

    (F) ensure the process for considering applications for medical staff membership and privileges affords each candidate for appointment procedural due process;

    (G) ensure in granting or refusing medical staff membership or privileges, the facility does not differentiate on the basis of the academic medical degree;

    (H) ensure that equal recognition is given to training programs accredited by the Accreditation Council on Graduate Medical Education and by the American Osteopathic Association if graduate medical education is used as a standard or qualification for medical staff membership or privileges for a physician;

    (I) ensure that equal recognition is given to certification programs approved by the American Board of Medical Specialties and the Bureau of Osteopathic Specialists if board certification is used as a standard or qualification for medical staff membership or privileges for a physician;

    (J) ensure that the medical staff is accountable to the governing body for the quality of care provided to patients;

    (K) ensure that a facility's credentials committee acts expeditiously and without unnecessary delay when a candidate for appointment submits a completed application, as defined by each hospital, for medical staff membership or privileges, in accordance with the following:

      (i) The credentials committee shall take action on the completed application not later than the 90th day after the date on which the application is received;

      (ii) The governing body shall take final action on the application for medical staff membership or privileges not later than the 60th day after the date on which the recommendation of the credentials committee is received; and

      (iii) The facility must notify the applicant in writing of the facility's final action, including a reason for denial or restriction of privileges, not later than the 20th day after the date on which final action is taken;

    (L) ensure the facility complies with the requirements for reporting to the Texas Medical Board the results and circumstances of any professional review action in accordance with the Medical Practice Act, Occupations Code, §160.002 and §160.003.

  (5) Facility administration. The governing body shall appoint a chief executive officer or administrator who is responsible for managing the facility.

   (6) Patient care. In accordance with facility policy, the governing body shall ensure that:


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